家庭医生签约服务对低收入人群中患高血压、2型糖尿病患者医疗卫生帮扶模式探讨

Study on Medical and Health Assistance Model of Family Doctor Contract Service for Low-income People with Hypertension and Type 2 Diabetes Mellitus

目的探讨家庭医生签约服务对低收入人群中患高血压、2型糖尿病患者医疗卫生帮扶模式——健康管理的效果。方法家庭医生签约服务团队成员对入选的低收入人群中患高血压、2型糖尿病患者,进行每月1次随访、每季度1次面对面随访,一年1次健康体检评估。结果通过对社区低收入人群中高血压、2型糖尿病患者医疗卫生帮扶,对比入组时和管理1年后,血压、血糖达标率明显提高、并发症未增加、对慢性病知识的了解提高。结论家庭医生签约服务能提高高血压、2型糖尿病患者对慢性病知识的了解,让此类人群也能得到有效治疗和管理,病情得到有效控制,减少并发症的发生,提高血压、血糖达标率。

Objective To explore the effect of family doctor contract service on health management, a medical and health support model for low-income people with hypertension and type 2 diabetes mellitus.Methods The members of the family doctor contract service team were followed up once a month, once a quarter, face to face, and once a year for health check-up evaluation of the selected low-income population with hypertension and type 2 diabetes mellitus.Results Through medical and health assistance for hypertension and type 2 diabetes mellitus in low-income community population, the rate of blood pressure and blood sugar reaching the standard was significantly increased, complications were not increased, and knowledge of chronic diseases was improved compared with that at the time of admission and one year after management.Conclusion Family doctor contract service can improve the knowledge of chronic diseases in patients with hypertension and type 2 diabetes mellitus,let such people can also be effectively treated and managed, the condition can be effectively controlled, the occurrence of complications can be reduced, blood pressure and blood sugar standards can be improved.